Multi-functional instruments and stretchable ligating and occluding devices

ABSTRACT

A multi-functional surgical device useful, for example, for male and female sterilization procedures. The device can be used for applying an elastic occluding ring onto an anatomical tubular structure, for cutting and cauterizing the cut ends of such a structure, for introducing a gas and/or anesthesia into the surgical field, for a biopsy procedure, for illuminating and viewing the surgical field, for applying a conventional clip to an anatomical tubular structure, and/or for applying a flexible and resilient ligature. An applicator device for applying a flexible and resilient ligature, plug or cap onto an anatomical tubular structure including tissue grasping forceps moved into and out of the distal end of a tubular member which has one or two anatomical tubular structure receiving slots. A flexible and resilient ligature, plug or cap having legs and a base having sufficient elastic memory to close the legs and occlude an anatomical tubular structure.

This invention relates generally to surgical devices and instruments,and, more particularly, to a multi-functional endoscopic and/ornon-endoscopic surgical device, which may be used to accomplish allphases of applying an occluding ligature to an anatomical tubular ornon-anatomical tubular organ structure. For example, the invention maybe used to occlude or sever the Fallopian tubes of a female or the vasdeferens of a male, or for vascular ligation, plugging anatomical lumenor encapsulating organ tissue structure.

Currently, there are numerous practices employed to effect sterilizationin women and men. One practice is to cut and tie the Fallopian tubes.Another practice is the use of an endoscope through which the Fallopiantubes can be electrically coagulated by a bipolar or unipolar instrumentto produce permanent sterilization. Another practice is the use of adeformable clip or elastic ring for clipping or occluding the tubes, vasdeferens, blood vessels or other organ structures. Clipping andoccluding procedures are potentially reversible disconnections ofanatomical tubular structures by application of one or more clips to thetubular structures or one or more elastic rings to loops formed in thetubular structures. Means and methods for accomplishing this procedurewith elastic rings are fully disclosed in my previous U.S. Pat. Nos.3,870,048, 3,911,923, 3,989,049, the teachings of which are incorporatedherein by reference, and others. The electric unipolar or bipolartechnique involves electrical cauterization of the Fallopian tubes, vasdeferens or blood vessels. Each of these procedures has its own, wellknown attendant advantages and disadvantages. The electric technique hasless chance of reversibility than clipping or occluding by elastic ringby way of reconstructive surgery.

Prior to the instant invention, there was no multipurpose instrument ordevice which could be used to accomplish any one of the tubularstructure occluding techniques noted above, and the attendant proceduresof injecting anesthesia, insufflation of an inert gas such as carbondioxide into the surgical field, taking a biopsy, coagulation, utilizingsuction, etc.

In summary, the electric coagulation technique, clip technique and ringtechnique have their own advantages and disadvantages which are alsorelated to the individual patient's age and the condition of the tubularstructure. In order to utilize the advantages of the above-mentionedthree major types of laparoscopic (endoscopic) anatomic tubularocclusion techniques and eliminate the disadvantages of thesetechniques, the instrument of the present invention can applyselectively all three techniques depending on the individualcircumstances at the time of the surgical procedure, and also can effectreversible sterilization without reconstructive surgery (in other words,by simple removal of the occluding devices, patients can be restored totheir fertility stages). There are two reversible occlusion techniquesin addition to the above-mentioned techniques which are plugging andFimbrial encapsulation, both of which can be accomplished with theinstrument of the present invention. This new and improved instrumentused with various occluding devices offers not only permanent orreversible occlusion but also various other endoscopic surgicalprocedures including ligating, clipping, plugging and/or encapsulatingsurgical procedures with interchangeable instrumentation.

SUMMARY OF THE INVENTION

Accordingly, it is a principal object of this invention to provide amulti-purpose surgical device for occluding an anatomical tubularstructure by any of the presently known techniques, the device beingfurther useful to accomplish all the ancillary procedures to accomplishocclusion of an anatomical tubular structure (e.g., sterilization).

It is a further object of the invention to provide an improved, flexibleand resilient or stretchable ligature for an anatomical tubularstructure which has sufficient elastic memory to accomplish occlusiononce released around or across an anatomical structure, such as theFallopian tubes or vas deferens.

It is another object of the invention to provide an improved,multi-functional surgical device for occluding an anatomical tubularstructure which is further combined with illumination and viewing means(e.g., a laparoscope), the viewing means including a swivel connectionto the multifunctional surgical device, thereby rendering the entirestructure far easier to use in accomplishing a surgical procedure.

Yet another object of the invention is to provide a surgical device toaccomplish sterilization by any one of a wide variety of methods, suchas electrical cauterization, cutting and tying the tubes, occlusion oftubes, plugging the utero-tubal junction or Fimbrial encapsulation, byapplication of a clip, plug, or elastic ring, or application of ashape-retaining, stretchable clip.

Still another object of the invention is to provide a new and improvedstretchable clip for occluding an anatomical tubular structure, the clipor ligature having sufficient elastic memory so as to grasp and firmlyocclude the anatomical tubular structure after release from an opened,distended state.

A further object of the invention is to provide such an improved,multi-functional surgical instrument having interchangeable forcepspermitting numerous surgical procedures with a single instrument system.

BRIEF DESCRIPTION OF THE DRAWINGS

Further and more complete objects and advantages of the invention willbecome readily apparent by reference to the following drawings in which:

FIG. 1 is a side, elevational view of a preferred embodiment of thesurgical device of this invention;

FIG. 2 is a side, elevational view of the outer tube or cylinder of thedevice shown in FIG. 1, drawn to an enlarged scale;

FIG. 3 is a side, elevational view of the middle tube or cylinder of thedevice shown in FIG. 1, drawn to an enlarged scale;

FIG. 4 is a partially exploded, side, elevational view of the innermember or cylinder of the device shown in FIG. 1, drawn to an enlargedscale;

FIG. 5 is a side, elevational view of an additional, elongate surgicalinstrument which may be inserted through the inner member illustrated inFIG. 4;

FIG. 6 is an exploded, bottom view of a handle which is used to extendand retract a forceps, the view being taken from the center portion ofFIG. 1 and drawn to an enlarged scale;

FIG. 7 is an elevational, exploded view taken from the right handportion of FIG. 1 and drawn to an enlarged scale;

FIGS. 8A and 8B are partial, side, elevational views illustrating amodification of the invention shown in FIG. 1, wherein the forceps atthe left of the view are provided with elements for taking a biopsy,FIG. 8A showing the instrument open and FIG. 8B showing the instrumentclosed;

FIG. 9 is a side, elevational view of the device or instrument shown inFIG. 1 provided with a laparoscope, there being a swivel connection ofthe laparoscope with respect to the instrument;

FIG. 10 is a side elevational, enlarged scale, partial sectional view ofthe forceps or distal end of the invention;

FIG. 11 is a view similar to FIG. 10, but showing other instrumentsextended from the distal end of the device;

FIG. 12 is a partial elevational view of an embodiment of the inventionhaving a tissue receiving slot formed in the distal end of the middletubular member;

FIG. 13 is a view similar to FIG. 12 but showing a pair of slots formedin the middle member distal end;

FIG. 14 is a view similar to FIG. 13 but drawn to an enlarged scale andillustrating one embodiment of a stretchable clip of this inventionmounted on the distal end of the middle member;

FIG. 15A is a perspective view of the stretchable clip illustrated inFIG. 14;

FIG. 15B is an elevational view showing the clip illustrated in FIG. 15Aoccluding a tubular anatomical structure such as a Fallopian tube;

FIG. 16 is an elevational, exploded view illustrating placement of theclip shown in FIG. 15A and the further step of surgical removal of asegment of the anatomical tubular structure located between the legs ofthe clip by a biopsy forceps;

FIG. 17 is a plan view of a package of clips and rings and the parts ofa loading device for mounting the clips onto the instrument;

FIG. 18A is a side, elevational view of another stretchable clip of thisinvention in an open position;

FIG. 18B shows the clip of FIG. 18A in place about an anatomical,tubular structure such as a Fallopian tube;

FIGS. 19A and 19B are views similar to FIGS. 18A and 18B, respectively,showing another embodiment of the stretchable clip of this invention;

FIGS. 20A and 20B are views similar to FIGS. 18A and 18B, showing yetanother embodiment of the stretchable clip of this invention;

FIG. 21 is a perspective view showing yet another stretchable clip ofthis invention;

FIG. 22 is a perspective view showing one method of placement of thestretchable clip shown in FIG. 21;

FIG. 23 is a perspective view showing another method of applying thestretchable clip illustrated in FIG. 21;

FIG. 24 through 39 are side elevational views, with parts broken away,of different types of forceps mounted on the distal end of the innertubular member of a surgical device of the present invention;

FIGS. 40 and 41 are side elevational views, with parts broken away, ofend and side suction devices, respectively, on the distal end of theinner tubular member of the present invention;

FIG. 42 is a side elevational view of a plug for the utero-tubaljunction constructed in accordance with the principles of the presentinvention;

FIG. 43 is a side elevational view, with parts broken away, of a furtherembodiment of the surgical device of the present invention, with theutero-tubal junction plug removably mounted thereon;

FIG. 44 is an exploded side elevational view, showing the surgicaldevice of FIG. 43, the plug of FIG. 42 and a pushing device for mountingthe plug on the surgical device;

FIG. 45 is a side elevational view of a needle construction that can beused in conjunction with the surgical device shown in FIGS. 43 and 44;

FIGS. 46 and 47 are plan views, with parts broken away, showing ahysteroscopic plug and a laparoscopic plug, respectively, inserted inthe utero-tubal junction;

FIG. 48 is a side elevational view of a fimbrial cap constructed inaccordance with the principles of the present invention;

FIG. 49 is a front elevational view of the fimbrial cap shown in FIG.48;

FIG. 50 is a side elevational view, with parts broken away, of anotherembodiment of the surgical device of the present invention, with thefimbrial cap removably mounted thereon;

FIG. 51, 52 and 53 are perspective views of the fimbrial cap, the rearportion thereof and the front portion thereof, respectively, shown inFIG. 48;

FIG. 54 is a perspective view of the fimbria at the entrance of theFallopian tubes; and

FIG. 55 is a perspective view showing the fimbrial cap positioned overthe fimbria shown in FIG. 54.

DESCRIPTION OF THE PREFERRED EMBODIMENTS

Referring now to the drawings by reference character and, in particular,to FIGS. 1-4 thereof, a preferred embodiment of the surgical device 10is shown, configured to apply either an elastic ring or stretchable cliponto a tubular, anatomical structure. Surgical device 10 includes aninner tubular member 12 which is slidably, telescopically receivedwithin a middle, tubular member 14 which, in turn, is telescopically,slidably received within an outer, tubular member 16. Each tubularmember 12, 14 and 16 has a distal end 18, 20 and 22 and a proximal end24, 26 and 28, respectively. Inner tubular member 12 has a forceps 30 ofany desired construction extending from its distal end 18. The innertubular member 12 may be of unitary construction or may be of two-piecetelescoping construction to prevent the proximal end thereof fromextending out of the proximal end of the device 10 in certainapplication. Forceps 30 are extended from and retracted into distal end20 of middle tubular member 14 by sliding inner tubular member 12 withinmiddle tubular member 14. This is accomplished by moving a surroundinghandle 32 which engages a peg 34 which depends from a medial portion ofinner tubular member 12, as is best illustrated in FIG. 4. The term"forceps" in the present application is intended to cover any type ofgripping or holding means including suction means or the like, theforceps shown in FIG. 4 having concave portions 30a at the distal endsof the forceps members and a hole 30b in the end of the lower forcepsmember.

The structure of handle 32 is best shown in FIG. 6. A slot 36 is formedat the forward end 38 of handle 32, and peg 34 is trapped therein by acap 40 threaded onto end 38. Referring to FIG. 3, middle tubular member14 has an elongated slot 42 formed in the bottom thereof and outertubular member 16 has a similar slot 44 formed in the bottom thereof.Slots 42 and 44 have, generally, the same dimensions and peg 34 extendsthrough slots 42, 44 as can be appreciated from FIG. 1. Thus, movementof handle 32 back and forth effects extension and retraction of forceps30 from distal end 30 of middle tube 14.

In order to accomplish an electrical cauterization procedure, peg 34 mayalso be a bipolar or unipolar electrical connector. Inner tubular member12 may include an additional electrical connector 46 which is shown atthe upper right hand portion of FIG. 1. Connector 46 may be a unipolaror bipolar electrical connector.

Proximal end 24 of member 12 may be threaded to receive an additionaltubular segment 48 which may be provided with a stop cock 50 and a port52. Port 52 may be connected, for example, to a pressurized supply of aninert gas such as carbon dioxide (not shown). Obviously, the gas willpass through the tubular member 12 to the surgical field. After the gasis introduced, stop cock 50 is closed to prevent the escape of the gas.

Turning now to FIG. 5, an instrument is illustrated which may beinserted through proximal end 24 of inner tubular member 12, into thesurgical field. This instrument may be in the form of an elongatedneedle or cannula 54, housed within a protective shield 56 forminginsulation when the needle conducts electricity or a shield when theneedle is used as a laser delivery device or probe. This instrument maybe provided to effect electrical cauterization. For example, end 58 ofthe instrument may be provided with a unipolar electrical connector 60.This instrument might also be used for the injection of anesthesia,application of an inert gas such as carbon dioxide into the surgicalfield, application of laser energy to the surgical field, or for other,known purposes.

With further reference to FIG. 1, a rotatable, threaded connector member62 is located on outer tubular member 16 between distal end 22 and thehandle 32 for the purpose of releasably securing the device 10 to alaparoscope (not shown) or the like.

Referring now to FIG. 1, right hand portion, and FIG. 7, a handlestructure is shown which is employed to eject a stretchable ligaturefrom the distal end 20 of middle tubular member 14. A generally U-shapedhandle 64 is provided which may be in one piece or may be centrallybifurcated at 66 into a first handle member 68 and a second handlemember 70. Handle members 68 and 70 may be pivotally connected at thebifurcation point 66 and a spring 72 may be provided to urge members 68and 70 apart.

With reference to FIG. 3, proximal end 26 of middle tubular member 14includes a depending, threaded post 74. The upper end of handle member68 is provided with an internally threaded member 76 for securing post74 to the handle member 68. Of course, post 74 extends downwardlythrough the elongated slot 44 of outer tubular member 16. The upper endof second handle member 70 includes a capture ring 78 through whichproximal end 28 of outer tubular member 16 is inserted. The proximal end28 of tubular member 16 is externally threaded at 80 to receive aninternally threaded capture cap 82. Thus, as handles 68 and 70 aresqueezed together, distal end 22 of outer tubular member 16 movestowards and slides over the distal end 20 of middle tubular member 14,thus to eject a stretchable ligature mounted on distal end 20.

The methodology for accomplishing this is well disclosed in my priorU.S. Pat. No. 3,989,049. This patent discloses the ejecting of one ormore elastic rings, such as is shown at 84 in FIG. 10. If multiplestretchable ligatures, plugs or caps are mounted on distal end 20, agauge 86 may be provided which controls the movement of the outertubular member 16 to eject the ligatures one at a time and to indicatethe number of ligatures being ejected. The gauge may be mounted oneither handle member 68 (FIG. 7) or handle member 70 (FIG. 1). The gaugemay be pivotally mounted as is shown at 87 so that it may be swung outof the way if it is not to be used and may be used as a locking orcontrol device for various occluding ligatures or devices.

For further security of structure, proximal end 26 of middle tubularmember 14 may be provided with a second, upstanding vertical post 88having a head 90. Proximal end 28 of outer tubular member 16 would beprovided with an upper, elongate slot 92 within which post 88 rides asouter tubular member 16 is moved axially relative to middle tubularmember 14, to eject a stretchable ligature in the manner just described.

With reference to FIG. 8A and 8B, a forceps structure is shown fortaking a biopsy. An interchangeable inner tubular member 12 is providedwith forceps 94 having cooperating, biopsy box members 96 and 98.Retraction of forceps 94 in the manner described above causes theforceps to close and grasp tissue at the ends while the biopsy boxmembers 96 and 98 cut and enclose a piece of tissue.

With reference to FIG. 9, the instrument 10 of FIG. 1 is shown incombination with a laparoscope 100. Outer tubular member 16 is receivedwithin main body 102 of laparoscope 100. A light source is provided at104. Laparoscope 100 includes an offset portion 104 having an eyepiece106. Conveniently, offset portion 104 is connected to main body 102 by aswivel connection 108. Swivel connection 108 permits the offset portion104 to be moved to a more comfortable position for the surgeon. Morespecifically, the surgeon need not stand directly behind the laparoscopebut may more comfortably, view the surgical field from the side of theinstrument.

FIG. 11 illustrates another forceps instrument for taking a biopsyincluding cooperating cutting members 110 and 112 disposed on oppositesides of instruments 54. The cutting portions 110 and 112 of the forcepsmembers are concave to cut and capture tissue therebetween, and pointedportions extend distally from the cutting portions for use in graspingthe tissue prior to cutting for biopsy purposes.

As briefly discussed above and disclosed in extended detail in, forexample, my prior U.S. Pat. Nos. 3,911,923 and 3,989,049, one method ofapplying a stretchable ligature to an anatomical tubular structureincludes extending forceps 30 about the tube, withdrawing forceps 30into proximal end 20 of middle tubular member 14 so as to crimp the tubeand form a loop therein (e.g., as shown here in FIGS. 22 and 23) andthen moving outer tubular member over middle tubular member 14 to ejecta stretchable ligature (such as elastic member 84) onto and over thelooped, anatomical tubular structure.

When the distal end 20 of middle tubular member 14 is completely closed,difficulty has been found in withdrawing an adequate amount ofanatomical tubular structure into the device so as to assure effectiveocclusion of tissue upon placement of the stretchable ligaturetherearound. With reference to FIG. 12, a distal end 20 of middletubular member 14 is illustrated having a tissue receiving slot 114formed therein. Excess tissue may be located within the slot during theprocedure so that an adequate amount of tubular structure is withdrawninto the middle tubular member 14. Also, the slot 114 allows the middletubular member to expand somewhat to facilitate the entry of the tubularstructure therein.

As shown in FIG. 13, a pair of tissue receiving slots 114, 116 areprovided which have generally similar dimensions. This structure permitsapplication of a stretchable ligature laterally across an anatomicaltubular structure and thus eliminates the need for forming a loop in thetube being ligated. Depending on the type of ligating device and thedistal configuration of the forceps being utilized, the tissue may ormay not be moved into the slots of the middle tubular member. Forexample, where forceps with kissing ends are used with a ligating deviceas shown in FIG. 15a, the tissue is moved to the distal end of themiddle tubular member and the ligature is applied thereto without entryof the tissue into the slots. When forceps with overlapping ends areused with a stretchable ring device, the tissue may be moved into theslots before the ring is applied thereto. The slots 114 and 116 alsoprovide increased space to accommodate tissue to be engaged, such astubes to be ligated which have a size so as not to be easily received inmiddle member 14 when forceps 30 draw the tube into the middle member toform a loop in the tube. That is, in a manner similar to that describedabove with respect to the single slot embodiment of FIG. 12, slots 114and 116 accommodate excess tissue to permit positioning of the tissue atthe distal end of member 14 and also allow the distal end of the middlemember to expand to accommodate a greater tissue volume. To this end,opposed slots 114 and 116 are disposed between the opposed members offorceps 30, as shown in FIG. 14; and, preferably, a plane passingcentrally through slots 114 and 116 is substantially transverse to aplane passing centrally through the opposed forceps members.Accordingly, the slots are disposed in the distal end of the middlemember at positions not angularly aligned with the forceps members; and,preferably, the slots 114 and 116 are aligned with the plane of the loopof a tube to be ligated such that the slots provide maximumaccommodation for excess tube tissue.

A first embodiment of a stretchable ligature of this invention isillustrated in FIG. 15A. This ligature includes a one-piece clip 118,formed of any non-tissue reactive, medical grade material that issuitable for implantation in the human body, having base portions 120,122 and pairs of cooperating legs 124, 126. At least the base portions120, 122 are made of a material having a sufficient elastic memory toforce the pairs of legs 124, 126, with or without engaging teeth, closedafter placement of the clip 118 over an anatomical tubular structure.Clip 118 is opened and forced over distal end 20 of middle tubularmember 14 in a manner to be described below. This is shown in FIG. 14.Forceps 30 are then manipulated to grasp an anatomical tube and pull thesame within the slots 114, 116. Outer tubular member 16 is then pushedover tubular member 14 to eject both clip 118 and the anatomical tubulartissue from the instrument. When ejected, the legs 124, 126 grasp andocclude the anatomical tubular structure under the urging of the base120, 122. The result is illustrated in FIG. 15B.

When conducting a sterilization procedure and in order to assure apermanent sterilization, the section of tubular tissue between the legs124, 126 may be severed and removed. This is illustrated in FIG. 16.After placement of clip 118 as described above, inner tubular member 12may be replaced with another instrument having spring-loaded blades 128,130 at the distal end 18 of the member 12 similar to the structure shownin FIG. 11. The blades are brought together by retracting the member 12within the intermediate tubular member 14, thus to sever a section 132from the anatomical tubular structure, it being appreciated that theconcave portions serve to cut and capture the tissue 132 while thepointed distally extending portions service to hold the tissue.Thereafter, an instrument 54 (FIG. 5) can be inserted within the innertubular member 12, the instrument 54 being connected to a source ofsuction (not shown). Instrument 54 is then extended into the surgicalfield and suction is applied to remove the excised piece 132.

FIG. 17 illustrates a package 134 including a pair of clips 118, a pairof elastic rings 119, a loading device 136 and a pushing device 138. Inorder to load a clip 118 onto distal end 20 of intermediate tubularmember 14, end 140 of loading device 136 is inserted into the distal end20. Clip 118 is slipped onto the narrowed end 142 of loading device 136.Pushing device 138 has a central aperture 144 and spring ends 146, 148.Pushing device 138 is inserted onto loading device 136 with end 142 ofthe loading device inserted through central aperture 144 of pushingdevice 138. The clip is then slid up the conical-shaped loading device136 and pushed onto distal end 20 of intermediate tubular member 14. Theresult is illustrated in FIG. 14. Similar structure for loading anelastic ligature is disclosed in my prior U.S. Pat. Nos. 3,911,923 and3,989,049.

Other embodiments of the ligatures of this invention are illustrated inFIGS. 18-20 inclusive. In FIG. 18A, a clip 150 is shown including anelastic memory base 152 and a clamp portion in the form of a single pairof cooperating legs 154, 156. An opening 158 is formed in base 152 sothat the clip 150 may be inserted onto proximal end 20 of intermediatetubular member 14 in the manner just discussed. FIG. 18B illustratesclip 150 after installation.

FIG. 19A shows a clip 162 having an elastic memory base 162 and opposedlegs 164, 166. Base 160 may extend the full length of legs 164, 166 (notshown). Clip 160 is illustrated in place, ligating an anatomical tubularstructure, in FIG. 19B.

Another clip 168 is illustrated in FIG. 20A, including a pair of elasticmemory bases 170, 172 joined by opposed legs 174, 176. FIG. 20B showsthe clip 168 ligating an anatomical tubular structure.

If desired, the facing surfaces of the legs of each of the clips justdiscussed may be serrated as is shown at 177 in order to assure that theclip is securely locked onto the anatomical tubular structure beingligated.

FIGS. 21-23 illustrate yet another stretchable ligature embodiment ofthis invention and two methods of placements of the ligature over andabout an anatomical tubular structure. A clip 178 includes a pair ofelastic memory bases 180, 182 which assume a quadrilateral configurationwhen forced open, as shown in FIG. 21. Bases 80, 182 are joined by apair of legs 184, 186. The facing surfaces of legs may be provided withmating engaging structures. For example, pins 188 extend inwardly fromleg 186 to be received in holes 189 in leg 184 and lock the legstogether to enhance locking of the clip 178 onto the tissue beingoccluded. As shown in FIG. 22, a large loop 190 is formed in the tissuebeing occluded and the clip 178 is applied well below the upper end ofthe loop 190. In FIG. 23, the clip is applied over the loop 190 withonly the base 180 performing the occluding function.

The term "ligature" as generally used in this application is intended tocover members such as rings, clips, plugs or caps for anatomical tubularstructures within the scope of the present invention.

Different types of forceps for mounting on the distal ends of theinterchangeable inner tubular members 12 are shown in FIGS. 24 through39. In accordance with the principles of the present invention, thesemodified forceps are mounted on inner tubular members which can bereadily interchanged with the tubular member 12 shown in FIG. 4,depending on the specific surgical application for the device 10 of thepresent invention. As illustrative examples, the forceps of FIG. 24 hasoverlapping end portions when they are closed and are suitable for usewith occluding rings, while the forceps of FIGS. 25 and 27 have"kissing" or abutting end portions when closed and are suitable for usewith stretchable clips. The forceps of FIG. 26 has a stationaryhook-like member and a movable member while the forceps of FIG. 28 has asingle hook-like member. The forceps of FIGS. 29 and 30 are providedwith recessed or concave areas for holding a tubular structure or thelike; the forceps of FIG. 31 has four members; the forceps of FIGS. 32and 35 are provided with portions for cutting and holding a biopsyspecimen; and the forceps of FIGS. 33, 34, 36, 37, 38 and 39 areprovided with additional members to combine needle-holding cutting andbiopsy functions along with clamping and scissor and knife cutting.

Referring to FIGS. 40 and 41, the distal end of the inner tubular member212 may be open at its end portion 213 (FIG. 40) or at a side portion215 (FIG. 41) for the purpose of applying suction to hold and movedelicate tissue to produce a suction forceps function.

As shown in FIGS. 42 through 47, the surgical device 10 of the presentinvention may be utilized to insert a plug or the like in theutero-tubal junction in a reversible sterilization procedure.

In a preferred embodiment, the plug 220 comprises a generallycylindrical base portion 222 and a plurality of flexible and resilientfingers 224 that are tapered to a pointed end portion and are normallyclosed, as shown in FIG. 42. In accordance with the operation of thesurgical device 10 hereinbefore described, the plug 220 is mounted onthe end portion of the middle tubular member 14 by being pushed thereonwith a pusher device 226 of any desired construction. In this manner,the fingers 224 of the plug 220 are opened such that it is slidable overthe middle tubular member 14 and is frictionally retained thereon, asshown in FIG. 43. Thereafter, the plug 220 may be inserted in theutero-tubal junction in a hysteroscopic procedure (FIG. 46) or alaparoscopic procedure (FIG. 47) by movement of the outer tubular member16 into engagement with the base portion of the plug to push it off themiddle tubular member 14 in a manner previously described herein. Ifdesired, a needle 228 (FIG. 45) may be inserted through the middletubular member 14 for the purpose of applying an anesthetic or the likeduring or before insertion of the plug 220 into the utero-tubaljunction.

Referring to FIGS. 48 through 55, the surgical device 10 of the presentinvention can also be utilized to position a cap 230 over the fimbria232 of the Fallopian tubes 234 in a reversible sterilization procedure.In a preferred embodiment, the cap 230 comprises an elongated, generallycylindrical body portion 236 with an elongated slit 238 therethrough sothat the cap can be expanded for mounting on the end portion of themiddle tubular member 14 in the manner shown in FIG. 50.

The cap 230 has an enlarged head portion 240 comprising a plurality ofnormally closed fingers 242 that are defined by transversed slots 244 inthe head portion. The cap 230 is made of any suitable flexible andresilient material, such as a suitable plastic material so that the bodyportion 236 and head portion 240 thereof are normally closed in themanner shown in FIGS. 48, 49 and 51.

In operation, the body portion 236 and head portion 250 of the caps 230are opened in any suitable manner to an extent such that the cap can beslidably and frictionally mounted on the distal end of the middletubular member 14 of the surgical device 10 in the manner shown in FIG.50. Through the use of suitable forceps 250 on the distal end of theinner tubular member 12, the tube 234 is grasped and then the cap 230 ispositioned over the fimbria thereof, as shown in FIG. 55, by moving theouter cylinder 16 of the surgical device 10 into engagement with thehead portion 240 of the cap 230 and pushing it off the middle tubularportion 14 in the manner previously described herein. It will beunderstood that the edges of the elongated slit 238 in the body portion236 of the cap 230 engage the mesosalpinx may be serrated or otherwiseconstructed to increase the gripping power of the plug when it ispositioned over the tube 234 by the surgical device 10.

The invention may be embodied in other specific forms without departingfrom the spirit or essential characteristics thereof. The presentembodiments are therefore to be considered in all respects asillustrative and not restrictive, the scope of the invention beingindicated by the appended claims rather than by the foregoingdescription and all changes which come from within the meaning and rangeof equivalency of the claims are therefore intended to be embracedtherein.

I claim:
 1. An applicator device for use in applying a flexible andresilient ligature, to an anatomical tubular structure or the like,comprising: an inner, elongated tubular member telescopically slidablyreceived within a middle elongated tubular member which, in turn, istelescopically slidably received within an outer, elongated tubularmember, said inner, middle and outer members each having a proximal endand a distal end, said inner member having forceps means mounted on adistal end thereof, means for moving said forceps means into and out ofsaid middle member, said distal end of said middle member beingconfigured to receive at least one ligature, thereon, and means forejecting a ligature, from said middle member whereby sliding movement ofsaid outer member with respect to said middle member and towards thedistal end thereof results in the distal end of the outer memberengaging the ligature, and ejecting the same from the middle memberdistal end.
 2. The applicator device as claimed in claim 1 furthercomprising first handle means slidable along and surrounding said outermember, said first handle means engaging said forceps moving meanswhereby upon movement of said handle means along the longitudinal axisof said outer cylinder, said forceps means is caused to move into andout of said middle member.
 3. The applicator device as claimed in claim1 wherein said forceps moving means further comprises a bipolarelectrical connector means for connection to a source of electricalcurrent.
 4. The applicator device as claimed in claim 1 wherein saidforceps moving means further comprises a unipolar electrical connectormeans for connection to a source of electrical current.
 5. Theapplicator device as claimed in claim 1 wherein a connector means ismounted on said outer member, between said outer member distal end andsaid handle means, for releasably connecting the device to a laparascopeor the like.
 6. The applicator device as claimed in claim 1 wherein saidmeans for ejecting a ligature, from said middle member furthercomprises, U-shaped handle means having two handle members, a firsthandle member being affixed to said middle member, a second handlemember being affixed to the proximal end of said outer member whereupona grasping, squeezing action on said U-shaped handle means causes saidouter member to move towards the distal end of said middle member, thusto eject a ligature, therefrom.
 7. The applicator device as claimed inclaim 1 wherein said middle member distal end is configured to receive aplurality of ligatures, said U-shaped handle means further includinggauge means for controlling and visually indicating the ejection of eachligature, from the middle member distal end.
 8. The applicator device asclaimed in claim 1 wherein said inner member is an elongated hollowcylinder internally configured to permit one or more additionalelongated instruments to pass therethrough.
 9. The applicator device asclaimed in claim 8 wherein said inner member proximal end extends beyondthe proximal ends of said middle and outer members and is provided withvalve means therein.
 10. The applicator device as claimed in claim 9wherein said inner member proximal end further includes a unipolarelectrical connector means for connection to a source of electricalcurrent.
 11. The applicator device as claimed in claim 9 wherein saidinner member proximal end further includes a bipolar electricalconnector means for connection to a source of electrical current. 12.The applicator device as claimed in claim 1 wherein an optical viewingmeans and an illuminating means are combined with the applicator device.13. The applicator device as claimed in claim 12, further comprisingmeans for swivel mounting of said viewing means with respect to saidapplicator device.
 14. The applicator device as claimed in claim 1wherein said middle member distal end further comprises means definingat least one slot means therein, arranged essentially parallel thelongitudinal axis of said middle member.
 15. The applicator device asclaimed in claim 14 wherein said middle member distal end furthercomprises two of said slot means therein.
 16. The applicator device asclaimed in claim 15 wherein said two of said slot means are ofsubstantially identical dimensions and are substantially laterallyaligned.
 17. The applicator device as claimed in claim 15, furthercomprising in combination a flexible and resilient ligature mounted onsaid middle member distal end and being in the form of an integral,one-piece member having at least one pair of leg means and an integralbase from which said leg means extend, at least said base means beingmade of a material having sufficient elastic memory such that the legmeans are normally closed, are opened against a closing force exerted bythe base means when the clip is inserted over said middle member distalend, and are closed again upon ejection from said middle member distalend.
 18. The applicator device as claimed in claim 17 wherein saidligature includes two pairs of said leg means.
 19. The applicator deviceas claimed in claim 1 wherein said forceps means are spring-loaded sothat they spring open when they are displaced from the distal end ofsaid middle member.
 20. The applicator device as claimed in claim 1wherein said forceps moving means comprises substantially elongated andco-extensive slot means formed through medial portions of both saidmiddle and outer members, and operative means affixed to a medialportion of said inner member and extending through said slot means,whereby movement of said operative means in a direction substantiallyparallel to the longitudinal axes of said members causes said forcepsmeans to move into and out of said middle member.
 21. The applicatordevice as claimed in claim 20 wherein said ligature ejecting meanscomprises post means affixed to said middle member and extendinglaterally through said slot means.
 22. The applicator device as claimedin claim 1 and further comprising an instrument removably insertablethrough said inner member including means for applying electrical energyto tissue.
 23. The applicator device as claimed in claim 1 and furthercomprising an instrument removably insertable through said inner memberincluding means for applying laser energy to tissue.
 24. The applicatordevice as claimed in claim 1 and further comprising an instrumentremovably insertable through said inner member including a needle forapplying anesthesia to tissue.
 25. The applicator device as claimed inclaim 1 including a plurality of interchangeable inner members carryingforceps means of differing configurations.
 26. An applicator device foruse in applying a stretchable ligature to an anatomical tubularstructure, comprising: an inner, elongated tubular member telescopicallyslidably received within a middle elongated tubular member which, inturn, is telescopically slidably received within an outer, elongatedtubular member, said inner, middle and outer members each having aproximal end and a distal end, said inner member having forceps meansmounted on a distal end thereof, means for moving said forceps meansinto and out of said middle member, means defining at least one slotmeans in the middle member distal end, arranged generally parallel thelongitudinal axis of said middle member; and means for ejecting astretchable ligature from said middle member dsital end by axiallydisplacing the middle and outer members relative to one another, in amanner such that the stretchable ligature effectively engages and closesa predetermined portion of the anatomical tubular structure.
 27. Theapplicator device as claimed in claim 26 wherein said middle memberdistal end further comprises two of said slot means therein.
 28. Theapplicator device as claimed in claim 27 wherein said two of said slotmeans are of substantially identical dimensions and are laterallyaligned.
 29. The applicator device as claimed in claim 26, furthercomprising in combination a flexible and resilient ligature mounted onsaid middle member distal end and being in the form of an integral,one-piece member having at least one pair of leg means and an integralbase from which said leg means extend, at least said base means beingmade of a material having sufficient elastic memory such that the legmeans are normally closed, are opened against the closing force exertedby the base means when the clip is inserted over said middle memberdistal end, and are closed again upon ejection from said middle memberdistal end.
 30. The applicator device as claimed in claim 29 whereinsaid ligature includes two pairs of said leg means.
 31. An applicatorfor use in applying a flexible, resilient device to bodily tissuecomprising an elongated tubular member having an open distal end with anouter surface for receiving a flexible, resilient device; a secondelongated member received within said first member and having a distalend carrying a forceps means for engaging tissue; means for operatingsaid forceps means to position tissue at said distal end of said firstmember; means for displacing a flexible, resilient device from saiddistal end of said first member to engage the tissue positioned thereat;and slot means disposed in said distal end of said first member at aposition not angularly aligned with said forceps means for accommodatingtissue during engagement of the tissue by a flexible resilient device.32. An applicator as recited in claim 31 wherein said forceps meansincludes a pair of forceps members with a first plane passing centrallytherethrough and said slot means includes a pair of slots with a secondplane passing centrally therethrough and disposed at an angle relativeto said first plane.
 33. An applicator as recited in claim 32 whereinsaid pair of forceps members are disposed in opposing relation and saidpair of slots are disposed in opposing relation.
 34. An applicator asrecited in claim 33 wherein said first and second planes are disposed intransverse relation.